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    My Dad is intubated in the ICU

    Bad weekend for my sweet Dad.

    He is almost 80 years old, injured 15 years ago (incomplete para L3 ASIA C) and has a lot of medical problems lately unrelated to his SCI. He is immunocompromised and has been having recurrent pneumonias and partial bowel obstructions that are likely caused by his massive paraesophageal (hiatal) hernia. He has had a couple brief hospitalizations from this over the summer, and has been recovering at home slowly with oxygen. On Friday he was working with the home PT and walking down his hall to the bathroom with his walker and bilateral AFOs. Hard, but possible.

    But he deteriorated over the next 36 hours and by late Saturday night was having fevers with night sweats, a swollen belly and shortness of breath. He was taken by ambulance to the ER early in the morning and intubated and is in the ICU with possible bowel obstruction and sepsis. He is very, very sick. When the ICU doctor saw that he was almost 80 with a spinal cord injury, she immediately encouraged us to not consider further care. I asked that they start treatment and at least figure out what is wrong and see if he responds to treatment, before giving up.

    Unfortunately, we are stuck in a small community hospital that is not experienced with his complexity of injuries. The ambulance drivers will not take us to the large tertiary care center that all his doctors work at, since it is further away. I am trying to get him transferred, but the big hospitals are full, the waiting list is long, and he is too unstable now to transport anyway.

    One problem is that we really really need to move his bowels, which may release his partial bowel obstruction. But he can't take any of his usual bowel medicines because he is not allowed to eat anything and has a tube draining his stomach in place. And the ICU doctor managing his case doesn't know anything about neurogenic bowel, and is resistant to doing what I ask her to do (!).

    Normally my Dad moves his bowels by sitting on an elevated toilet seat and doing some digital stimulation and some straining. He cannot do any straining now because he is sedated, in bed. His normal bowel meds are misoprostol 400mcg four times a day and Miralax twice a day, and he can't take either.

    What would you recommend as the most aggressive method to try to move his bowels from below? Unfortunately, he doesn't respond well to most suppositories, enemeeze or enemas, which is why he uses the other meds/techniques. But maybe if we try to stack them aggressively..... once we did something like this...... place a dulcolax suppository... wait an hour.... try a fleet enema.... wait an hour.... still nothing, try a 2nd different enema.... and then he did move his bowels.

    What would you recommend?

    Today the doc finally said she would try a suppository, but only gave him a colace suppository, which of course did nothing. I asked them multiple times to try to stack the treatments and try digital stimulation and say I was willing to assist this myself and they just wouldn't do it. I am going back early tomorrow to catch the attending/senior doctor to push them. This could be devastating if he doesn't get his bowels moving to release the obstruction. I am very worried.

    #2
    hlh, sending positive energy, hang in there!

    Comment


      #3
      Would need to use Bisacodyl suppository or Enemeez 5ml should be safe. CWO
      The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

      Comment


        #4
        Originally posted by SCI-Nurse View Post
        Would need to use Bisacodyl suppository or Enemeez 5ml should be safe. CWO
        If the first one doesn't have an effect, would you stack them.... then use the next one? When - at what interval? And when would you do the Digital Stim relative to the suppository/enemeez?

        Comment


          #5
          I will step in here and say how sorry your dad is in such serious medical condition.

          Years ago we used to give liquid Colace enemas for bad impactions. It's pretty messy as liquid Colace is high in sugar (as it is usually used orally) and everything ends up sticky, but it usually did work. I'm assuming he is not allowed anything orally, as in that case I usually recommend Lactulose 1 tablespoon every 2 hours until a significant stool is expelled.

          (KLD)
          The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

          Comment


            #6
            Originally posted by Jim View Post
            hlh, sending positive energy, hang in there!
            Thank you Jim. Truly.

            Comment


              #7
              Originally posted by SCI-Nurse View Post
              I will step in here and say how sorry your dad is in such serious medical condition.

              Years ago we used to give liquid Colace enemas for bad impactions. It's pretty messy as liquid Colace is high in sugar (as it is usually used orally) and everything ends up sticky, but it usually did work. I'm assuming he is not allowed anything orally, as in that case I usually recommend Lactulose 1 tablespoon every 2 hours until a significant stool is expelled.

              (KLD)

              Thank you for your thoughts, KLD.

              Yes, he is NPO, intubated with an NGT.

              I appreciate the colace enema suggestion. It likely isn't available here but I will ask.
              Today I at least got them to try a dulcolax suppository and I found a GI NP who understood neurogenic bowel and did dig stim. But they have stalled with repeating the stim/suppository/enema, as dulcolax alone won't work.

              Thanks again.

              Comment


                #8
                hlh, I am so, so sorry that this is happening and wish I had even a small suggestion for making your dad more comfortable. I truly understand your frustration (paltry word - anguish is more like it) and rage that must be suppressed in order to get ignorant, arrogant hospital personnel to do the helpful things it's taken you years to discover. I had a similar situation with my father, though his was a heart issue, and I just want to say that I'm praying in my fashion for more enlightened professional minds to be found, and prevail. May ways open for you to get the help your father needs, and may lightbulbs go off all around your head so that, in spite of bone-weariness, even small opportunities will be crystal clear.
                MS with cervical and thoracic cord lesions

                Comment


                  #9
                  Originally posted by Bonnette View Post
                  hlh, I am so, so sorry that this is happening and wish I had even a small suggestion for making your dad more comfortable. I truly understand your frustration (paltry word - anguish is more like it) and rage that must be suppressed in order to get ignorant, arrogant hospital personnel to do the helpful things it's taken you years to discover. I had a similar situation with my father, though his was a heart issue, and I just want to say that I'm praying in my fashion for more enlightened professional minds to be found, and prevail. May ways open for you to get the help your father needs, and may lightbulbs go off all around your head so that, in spite of bone-weariness, even small opportunities will be crystal clear.
                  Thank you Bonnette.

                  I am so sorry to hear that you can relate to this from personal experience. It is a little bit of torture.

                  I appreciate your good wishes more than you can know.

                  Comment


                    #10
                    Did the KUB show an ileus or an impaction. The results of the xray drive the recommendation. How ling has it been since he had a bm? If no chance of obstruction then could proceed with whatever his bowel program was at home. If that didn’t work then could try a Fleets mineral oil but phosphasoda Fleets not recommended to use more than once to repeat due to potential electrolyte imbalances. He is being seen by a gastroenterologist? Never have seen colace enemas being used, not in over 43 years at least. Enemeez is a tsp of Docusate Sodium, also a stool softener that is taken by mouth. Is the NG tube to suction? Are they putting medication done it? If so liquid stool softener recommended. CWO
                    The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

                    Comment


                      #11
                      Originally posted by SCI-Nurse View Post
                      Did the KUB show an ileus or an impaction. The results of the xray drive the recommendation. How ling has it been since he had a bm? If no chance of obstruction then could proceed with whatever his bowel program was at home. If that didn’t work then could try a Fleets mineral oil but phosphasoda Fleets not recommended to use more than once to repeat due to potential electrolyte imbalances. He is being seen by a gastroenterologist? Never have seen colace enemas being used, not in over 43 years at least. Enemeez is a tsp of Docusate Sodium, also a stool softener that is taken by mouth. Is the NG tube to suction? Are they putting medication done it? If so liquid stool softener recommended. CWO

                      The abdominal CT scan shows some ileus/possible partial small bowel obstruction type changes but they are intermittent/chronic. No impaction. His stool burden is always high, and that is normal for him. He was moving his bowels every day until he came to the hospital Sunday morning, and even moved his bowels that morning. I just couldn't convince the team how important it was for him to move his bowels and how damaging it is for someone like my Dad to suddenly stop all of his bowel meds when moving his bowels has been shown in the past to decompress his GI tract in exactly this situation.

                      So we can't do the bowel program from home, because that is taking Miralax twice a day, misoprostol twice a day, sitting upright on a toilet and doing digital stimulation, and straining. He is sedated, in bed, intubated and he is NPO. The NGT is to suction.

                      Even if he had a bowel obstruction, he is not a surgical candidate and will not decompress on his own without moving his bowels and the sepsis like picture will not improve unless we decompress, as the only cause of his sepsis that has been proposed so far that is likely is that it is from his chronic bowel situation that was slowly causing bacterial translocation.

                      This hospital is so small their ICU has only 6 people in it, and half of them are walking around the halls. Their GI attending has not been helpful so far, unfortunately. The only reason we are starting to treat his bowels is that the Surgery attending gets it a little, because he has seen my Dad before and understands the CT scan and knows he needs to move his bowels to help, but he just doesn't understand neurogenic bowel and can't give any specific recs.

                      I know that I need to give him multiple stimulants from below, in succession. I just was hoping for some specific recs on how to do it, to try to kick things off faster. Trying a colace suppository one day.....once.... and then the next day try a dulcolax suppository.... once.... will not do it. Stimulants from below never helped my father much at all in the past, which is why they aren't part of his normal bowel program. But dig stim helps some.

                      Comment


                        #12
                        The first thing is to clear the rectal vault manually, with finger. All rectal medication including suppositories and Enemeez(Docusate Sodium 283 rectal) and medicated enemas must come in contact with the rectal mucosa where it absorbed. If it is just inserted into a wad of poop they won’t work. Most nurses and few medical professionals… even in SCI do not do this. Enemeez -ir its generic-same company-is not a chemical irritant like Bisacodyl and it works well and fast on most people. And new formula has Miralax in it also. I would try this first but if not on the formulary them an issue. Next choice 4 os . Fleets. Hopefully the ileus will be resolved soon.To clear out the lower portion is needed so when the ileus clears things can move. This also contributes to the ileus. In addition, no problem with back to back enemeez or Magic bullet. And dig stim. Would the MD feel more comfortable if they had a copy of the guidelines on SCI Neurogenic Bowel? You might look in to Peristeen or transanal irrigation after discharge. CWO
                        The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

                        Comment


                          #13
                          Thank you for all of your input CWO!

                          Enemeez and Peristeen did not work well for my Dad in the past. A colace suppository alone didn't help now in the ICU. But I ordered Enemeez. They definitely do not have that at our hospital and wont take my (old....) samples to use. I hadn't realized that it contains PEG now. Thanks for the heads up!

                          So far they have only tried one mineral oil enema - and now they are out of stock/on back order - and a water enema, both without much success. I will push on the Fleets as well.

                          If you use things back to back, how exactly do you do it? How long do you wait between? Dig stim before inserting each new thing?

                          Comment


                            #14
                            Of course, my Dad has already had bad skin issues. They were able to get him on a LAL mattress, but not for the first day in the ER/ICU and his turn schedule has been erratic at best. When he is critically ill, there is only so much I can do with pushing the nurses before they totally hate me, and I also don't want my Dad to crash.

                            His old left lower butt cheek pressure wound/scar near the scrotum (from his old toilet seat) rapidly deteriorated. By the 2nd day in the ICU, it was bring red with a purple core, and yesterday the whole outer layer of skin peeled off like an opening huge blister, at least 3-4cm round. The core is also darker colored, so a deeper injury is likely.

                            They have a wound care nurse, who is somewhat knowledgeable, but who unfortunately thinks the LAL mattress alone should "prevent" these injuries without turning from happening and suggested it started before he came to the hospital. Of course, I know she is just trying to protect the hospital from liability.

                            He is so high risk. Almost 80. SCI. Not eating with terrible nutrition numbers due to sepsis. Intubated. Not moving, irregular turn schedule. Not able to download it completely because some turns go towards that left side. He has to keep the head of the bed > 30 degrees to prevent aspiration, and also turning to the right increases aspiration risk for him, although I will encourage them to try a soft turn to the right. And of course, the bed is too short for him and we have to pull him up often. His skin is sheared when the nurses turn him for bowel care, skin care, other repositioning etc...

                            The wound is washed, covered with a Mepilex. Suggestions?

                            I will try to lower the head of the bed to 30 degrees, if tolerated. I will try to get a Q2 hour turn schedule better adhered to. I am not sure how to avoid having time on his back/left side, which may put pressure on the area. I will try to talk to nutrition to see if there is anything that could be added, even while he intubated/NGT to suction/NPO.

                            Ugh.

                            Comment


                              #15
                              I am so sorry your dad is in that situation. What is the reasoning for being NPO still? They cannot put meds down that NG tube at this point?

                              I'm guessing he would be NPO if they were considering taking him to surgery to address an obstruction since at some point the bowel would die off and would need to be resected. Imaging would drive that surgery recommendation I would think. But if they're deeming obstruction is not the cause then why are they not getting more aggressive with enteral bowel meds?

                              Or parenteral nutrition?

                              I really wish this country had IryPump like I use. I had to really go out of my way to find a pharmacy in another country to buy them for me. Such a hassle but I bought 2 to make sure I have them well into the future. Colonic irrigation by powered pump is the best.

                              Is he on large amounts of opioids? Maybe consider methylnaltrexone, it's given as an injection to treat opioid induced constipation by blocking peripheral opioid receptors.
                              Last edited by paraparajumper; 22 Sep 2022, 5:28 PM.

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